1. Economic and Social Aspects of NCDs SDE Seminar Series/PAHO 25 April, 2012 Rachel Nugent

2. 5 Key Trends First, chronic diseases already pose a substantial economic burden, and this burden will evolve into a staggering one over the next two decades.

3. 5 Key Trends Second, although high-income countries currently bear the biggest economic burden of chronic diseases, countries in the developing world, especially middle-income, are expected to assume an increasing share as economies and populations grow.

4. 5 Key Trends Third, the marginal costs for governments of achieving maximal adult survival are rising, in contrast to declines in marginal costs of achieving child survival. This divergence is a consequence chiefly of the lack of sustained investments in new drugs, and the lack of existing infrastructure, strategies and program implementation for chronic diseases.

5. 5 Key Trends This leads to the fourth conclusion, which is that addressing chronic disease in poor countries requires rethinking developmental assistance and creating new delivery approaches. Development assistance is insufficient to deliver needed care and services. Should focus on research, espec. Implementation science. CCM and patient-centered approaches are more likely to be effective and sustainable, but need further testing and costing.

6. 5 Key Trends Finally, selected options available to prevent and control chronic diseases appear to justify themselves in economic terms in the sense that the welfare gains and the economic losses that could be averted by investments that would reduce chronic diseases are considerably larger than those investments.

7. MaleFemale NCDs kill people at a younger age in developing countries Age-standardized deaths per 100,000 from cardiovascular disease 7 Source: WHO, 2008 Age-standardized deaths per 100,000 from cardiovascular disease and diabetes The highest increases in NCDs are expected in Africa, South-East Asia, and the Southern Mediterranean—an over 20 percent increase expected by 2020. Source: WHO, 2010

8. The future of aging Epidemiological Transition –Aging population and lifestyle changes imply chronic disease is becoming the main source of mortality in middle- and low-income countries Postponable Mortality –Death after age 70 years is inevitable –Death below age 30 years could become rare –Death from ages 30-69 need not be common

9. CGHR.ORG Economic benefits of reduced mortality Income growth Welfare (value of reduced mortality and better quality of life) Poverty reduction

10. Unequal burden within and across countries Indian “Million Death Study” finds the highest burdens of cancer, stroke, and heart attacks are in the least educated and rural areas (RGI, CGHR, 2009). Median OOP expenditures for Tx of heart attack ranged from $347 (TZ) to $2914 (India). Additional costs were declines in functional health and lower productivity (Huffman et al 2011). CVD is leading to greater divergence in health equity across countries (Becker 2009).

11. Priority chronic disease interventions StrokesCardiovascular Disease CancersRespiratory disease Mental illness Identified based on: –cost-effectiveness –size of the disease burden they address –Feasibility of implementation

12. Chronic Disease Control: Key Investment Priorities Reducing tobacco use Salt Reduction Management of acute and chronic vascular diseases –Low-cost generic risk pills for vascular disease –Prevention of obesity and diabetes –Comparison of smoking and obesity risks

13. Chronic Disease Control: Key Investment Priorities Table 6. CHRONIC DISEASE CONTROL: KEY INVESTMENT PRIORITIES Priority Area Indicative Benefit- Cost Ratio Level of Capacity Required a Financial Risk Protection Provided a Relevance for Development Assistance a Annual Costs ($ billions)Annual Benefits b 1. Cancer, heart disease, other: tobacco taxation 40:1 H HH 0.5 1 million deaths averted or 20 million DALYs 2. Heart attacks (AMI): acute management with low-cost drugs 25:1 M HH 0.2 300,000 heart attack deaths averted each year or 4.5 million DALYs 3. Heart disease, strokes: salt reduction 20:1 H HH 1 1 million deaths averted or 20 million DALYs 4. Hepatitis B immunization 10:1 H HH 0.1 150,000 deaths averted or 3 million DALYs 5. Heart attacks and strokes: secondary prevention with 3-4 drugs in a “generic risk pill” 3:1 H HH 32 1.6 million deaths averted or 108 million DALYs averted a Level of capacity required, extent of financial risk protection provided and relevance for development assistance, are judged by the authors to be high (H), medium (M) or low (L). b In the formulation of DALYs the benefits of averting a death in a given year all accrue in that year and are calculated as the present value (at a 3% discount rate) of the future stream of life years that would have occurred if the death had been prevented.